Yet stop-gap measures, such as double shifts when someone’s on vacation, only work for so long, he points out. “You can’t continue to keep doing that as you’re being asked to see more and more patients, do more and more teaching, do more and more oversight, and still do it with the same number of people.”
Hospitalists’ great reputations for providing more efficient care and decreasing length of stay may convince institutions it’s worth it to change their staffing models and add more people. “Hospitals are running at capacity,” he says. “You still need quality.”
8) Improve communication: Pick up the phone. “One of the big things we’ve been working on is physician-to-physician communication,” Dr. Thoelke says. “That’s another problem area at many large academic institutions, and I think at most community institutions as well.”
Every consult should lead to a phone call, not just a note in a chart that another doctor might not see until the next day. It’s not only for courtesy’s sake: Dr. Thoelke believes that better, more direct communication will further decrease length of stay.
“You gather so much more information even in brief conversations from one doctor to another,” Dr. Thoelke says. “I object personally when I have a consultant schedule my patient for a test that they don’t make me aware of. I’m on the phone saying, ‘This is not appropriate.’ I’m the person who’s going to be dealing with the complications of this procedure. So I’m pushing back directly to physicians.”
He’s also working hand in hand with hospital administration to encourage a culture of communication.
A standardized hand-off of every patient, every time, would also help, says Dr. Landrigan.
“As it stands now, there’s a lot of looseness,” Dr. Landrigan says. Physicians sometimes assume that the next clinician can simply take over. “The reality is that when clinicians know the patients less well, care suffers.”
An SHM task force has created basic standards for hospitalists to use for hand-offs (The Hospitalist August 2007, p.18).
9) Meet face to face with all those involved when you want to make change. No matter what’s on your wish list for 2008, your chances of making it happen improve if you communicate directly, according to Dr. Ford.
“I would recommend this not just for hospital medicine, but for anything,” Dr. Ford says. “You really have to go and meet with people. You really have to communicate, and not just by e-mail. E-mail is a good way to set up times to meet.”
To build support for the changes he wanted to make at Temple when Cogent Healthcare began managing its hospitalist program, Ford brought everyone into the discussion, from medical department chairs to representatives from nursing, administration, the labs, and more. “All the key stakeholders,” he says.
Now, Temple’s overall culture focuses on the institution’s financial health as well as on patient health. It also has an observation unit run entirely by hospitalists, freeing residents to work on other cases and still comply with ACGME rules.
“We did get a lot of resistance,” Dr. Ford admits. “University faculty weren’t very receptive to having a non-university faction running this unit. We had to break down the stereotypes that we weren’t a for-profit monster. We had to gain the trust of the emergency department [and others] to allow us to take care of their patients.” TH
Liz Tascio is a journalist based in New York.